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Achieving Glycemic Control in the Hospital Setting

Achieving Glycemic Control in the Hospital Setting. (Part 2 of 4). 143357. Selected Randomized Controlled Trials of Intensive Glucose Management in Critical Care Studies Showing No Benefit.

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Achieving Glycemic Control in the Hospital Setting

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  1. Achieving Glycemic Control in the Hospital Setting (Part 2 of 4) 143357

  2. Selected Randomized Controlled Trials of Intensive Glucose Management in Critical Care Studies Showing No Benefit *Blood glucose in mg/dL; †RRR=Relative risk reduction, intensive group vs conventional group; ‡Personal communication; Dr. Frank Brunkhorst; §P<.05; ¶Not significant (P>.05). 1. Van den Berghe G et al. N Engl J Med. 2006;354(5):449-461; 2. Devos P et al. Intensive Care Med. 2007;33:S189; 3. Gandhi GY et al. Ann Intern Med. 2007;146(4):233-243; 4.Brunkhorst F et al. N Engl J Med. 2008;358(2):125-139; 5. De La Rosa G et al. Crit Care. 2008;12:R120; 6. The NICE-SUGAR Study Investigators et al. N Engl J Med. 2009;360(13):1283-1297.

  3. NICE-SUGAR Study: Design • Multicenter, open-label, randomized, controlled trial • Examining the effects of blood glucose management on 90-day, all-cause mortality • The 2 groups had similar baseline characteristics • 42 Centers in Australia, New Zealand, and Canada • Recruitment from December 2004 to November 2008 • Last follow-up: November 2008 Intensive control group(target BG: 81-108 mg/dL) n=3054 Eligibility: Patients expected to require treatment in the ICU for 3 or more consecutive days N=6104 Conventional control group(target BG: ≤180 mg/dL) n=3050 The NICE-SUGAR Study Investigators. N Engl J Med. 2009;360(13):1283-1297.

  4. NICE-SUGAR Study Results: Treatment and Glucose Measures IQR=interquartile range. The NICE-SUGAR Study Investigators. N Engl J Med. 2009;360(13):1283-1297.

  5. NICE-SUGAR Study: Outcomes The NICE-SUGAR Study Investigators. N Engl J Med. 2009;360(13):1283-1297.

  6. NICE-SUGAR Study: Trial Limitations • Subjects eligible for inclusion were defined by a subjective rather than an objective criterion, which was the expected time in the ICU • Medical staff and study personnel were not blinded to treatment arms • Several patients in the intensive-control group had glucose levels above the target range • Data regarding potential biological mechanisms underlying the observed outcomes in the intervention groups were not collected • Data regarding the costs of the trial interventions were not collected The NICE-SUGAR Study Investigators. N Engl J Med. 2009;360(13):1283-1297.

  7. NICE-SUGAR Study: Conclusions • This large, international, randomized trial found that intensive glucose control did not offer benefits to critically ill patients1 • Blood glucose target of <180 mg/dL with the achieved target of 144 mg/dL resulted in lower (90-day) mortality than did a target of 81-108 mg/dL1 • Increased hypoglycemic events were observed with lower glucose targets1 • ADA and AACE position: good glucose management, through establishing patient-specific glycemic targets and individualizing care, are important objectives for patients in the hospital setting2 1. The NICE-SUGAR Study Investigators. N Engl J Med. 2009;360(13):1283-1297. 2. Joint statement from the American Diabetes Association (ADA) and American Association of Clinical Endocrinologists (AACE) on the NICE-SUGAR study on intensive versus conventional glucose control in critically ill patients. American Diabetes Association Web site. http://www.diabetes.org/for-media/2009/joint-statement-from-ada-and.html. Accessed December 17, 2009.

  8. How Have These Data Changed Management Paradigms?

  9. Guidelines for Glycemic Control in Hospitalized Patients Intensive Care Unit BG≤180 mg/dL • With initiation of insulin therapy, maintain between 140 and 180 mg/dL; potential for better therapeutic outcomes at the lower range1 • Somewhat lower targets might be recommended for selected patients, but targets <110 mg/dL are not recommended1 • Prolonged treatment with sliding-scale insulin as the sole regimen is discouraged1 • Consideration should be given to minimizing the risk of hypogylcemia (a never event), which is associated with adverse short- and long-term outcomes among inpatients1,2 1. Moghissi ES et al. Endocr Pract. 2009;15(4):353-369; 2. Eliminating serious, preventable, and costly medical errors—never events [news release]. Centers for Medicare & Medicaid Services. http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=1863. Accessed December 17, 2009.

  10. Guidelines for Glycemic Control in Hospitalized Patients (cont’d) Noncritical Care Preprandial: <140 mg/dLRandom: <180 mg/dL • Reassess treatment regimen if BG <100 mg/dL • Modify treatment if BG <70 mg/dL, unless caused by other known factors (eg, missed meal) • Stable patients with successful prior history of tight glycemic control in outpatient setting might be good candidates for lower ranges • Higher ranges might be appropriate for certain patients* *Patients who are terminally ill, patients with severe comorbidities, and patients in care settings where frequent BG monitoring is not possible. Moghissi ES et al. Endocr Pract. 2009;15(4):353-369.

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